Pilot Debrief

EUROCOPTER AS-350-B2 near Mosby, MO — 2011-08-26

Final reportCEN11FA599
Sign in to save
Date
2011-08-26
Location
Mosby, MO, USA
Airport
GPH
Aircraft
EUROCOPTER AS-350-B2
Registration
N352LN
Category
Helicopter
Highest injury
Fatal
Fatalities
4
Phase of flight
Cruise

Probable cause

The pilot's failure to confirm that the helicopter had adequate fuel on board to complete the mission before making the first departure, his improper decision to continue the mission and make a second departure after he became aware of a critically low fuel level, and his failure to successfully enter an autorotation when the engine lost power due to fuel exhaustion. Contributing to the accident were (1) the pilot's distracted attention due to personal texting during safety-critical ground and flight operations, (2) his degraded performance due to fatigue, (3) the operator's lack of a policy requiring that an operational control center specialist be notified of abnormal fuel situations, and (4) the lack of practice representative of an actual engine failure at cruise airspeed in the pilot's autorotation training in the accident make and model helicopter.

Contributing factors

Contributing to the accident were (1) the pilot's distracted attention due to personal texting during safety-critical ground and flight operations, (2) his degraded performance due to fatigue, (3) the operator's lack of a policy requiring that an operational control center specialist be notified of abnormal fuel situations, and (4) the lack of practice representative of an actual engine failure at cruise airspeed in the pilot's autorotation training in the accident make and model helicopter.

NTSB narrative

The Safety Board’s full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-13/02. On August 26, 2011, about 1841 central daylight time, a Eurocopter AS350 B2 helicopter, N352LN, crashed following a loss of engine power as a result of fuel exhaustion near the Midwest National Air Center (GPH), Mosby, Missouri. The pilot, flight nurse, flight paramedic, and patient were killed, and the helicopter was substantially damaged by impact forces. The emergency medical services (EMS) helicopter was registered to Key Equipment Finance, Inc., and operated by Air Methods Corporation, doing business as LifeNet in the Heartland, as a 14 Code of Federal Regulations Part 135 medical flight. Day visual meteorological conditions prevailed at the time of the accident, and a company visual flight rules flight plan was filed. The helicopter was not equipped, and was not required to be equipped, with any onboard recording devices. The flight originated from Harrison County Community Hospital, Bethany, Missouri, about 1811 and was en route to GPH to refuel. After refueling, the pilot planned to proceed to Liberty Hospital, Liberty, Missouri, which was located about 7 nautical miles (nm) from GPH.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Refueling decision could have been made earlier to prevent fuel exhaustion.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 125 docket documents
View NTSB final reportView NTSB docket

Docket documentsshowing 50 of 125

Related mishaps